Endovenous Laser Ablation (EVLA) of Great Saphenous Vein to Abolish “Paradoxical Reflux” in the Giacomini Vein: A Short Report

The Giacomini vein, described in 1873, is a proximal extension of the small saphenous vein in the thigh. It is present in 50–80% of the population,^,  and in >50% of the patients it terminates at the great saphenous vein (GSV) in the thigh. This inter-saphenous connection may transmit reflux from the proximal GSV to the SSV (descending or orthodox reflux) or from the sapheno-popliteal junction (SPJ) to the GSV (ascending or paradoxical reflux). In paradoxical reflux, blood from the SPJ ascends through the Giacomini vein to the GSV in the thigh and feeds more distal varicosities associated with the GSV. Ante-grade flow through the Giacomini vein occurs during both systole (compression) and diastole (relaxation) of the calf muscle and is a striking feature of this type of reflux which is responsible for about 1% of primary varicose veins. Although there is no consensus regarding the optimum treatment for this type of reflux, surgical division of the Giacomini vein flush with the SSV and the GSV has been described.

This article describes a new approach to the treatment of varicose veins due to paradoxical Giacomini vein reflux by endovenous laser ablation of the incompetent segment of GSV. The relevant fluid mechanics underlying this method of treatment are discussed.

Two patients aged 46 and 52 years (1 male, 1 female) presented with symptomatic primary varicose veins (aching, pruritus), without skin changes. Duplex ultrasonography (DUS) confirmed that the SFJ, proximal GSV and SSV were all competent. There was reflux at the SPJ and in the distal GSV. The Giacomini vein, which terminated at the GSV, was identified in both patients and ante-grade flow was noted during both calf muscle squeeze and release. DUS also confirmed that the varicosities were not arising from the SSV. Endovenous laser ablation (810 nm diode laser, 12 W power, 1 second pulse with 1 second intervals 60–72 J/cm) of the GSV was performed from the mid-calf proximally beyond the junction with the Giacomini vein. Following treatment a non-stretch compression bandage was applied for one week followed by a class 2 support stocking for a further week. At six weeks, DUS confirmed that both GSVs were occluded throughout the treated lengths and that the SPJs had become competent. The majority of visible varicose veins had disappeared although one patient required sclerotherapy for a residual varicosity. The improvement in symptom severity scores are shown in Table 1 and symptoms had resolved fully in both patients. No reflux was demonstrated in the SSV in either patient, and the diameter of the Giacomini vein had decreased (see Table 2) with ante-grade flow during calf muscle squeeze but no flow following calf release. At 12 weeks the treated GSV was no longer visible on DUS and no residual or recurrent varicose veins were present. The SFJ, SPJ, Giacomini vein and SSV were all competent. The duplex ultrasound scan findings are summarized in Table 2.

Blood flows as a continuous column and therefore reflux in one segment of vein is filled by ante-grade or retrograde blood flow in another vein. Appreciation of this is necessary to understand the pattern of reflux and to plan effective treatment for varicose veins. In paradoxical reflux, although the blood from SPJ ascends through the Giacomini vein against gravity, the blood eventually flows downwards to fill the GSV varicosities that are located below the level of the SPJ. Even though blood appears to flow against gravity initially, the overall net-travel effect in the direction of gravitational force. Thus, the cardinal sign of paradoxical reflux in these patients was the cephalad flow in the Giacomini vein during calf muscle release. In this type of paradoxical reflux, the SSV remains competent due to a healthy valve at the proximal vein, even though the SPJ becomes incompetent. A competent SFJ and proximal GSV are the other characteristic features of this type of reflux (Fig. 1). This pattern of paradoxical reflux can be simulated in a simple experimental model (Fig. 2). Water ascends through the tube segment “AB” before it descends in tube segment “CD”. Water flow in this model is only possible as long as the point D is lower than the point A, effectively working as a syphon. Abolition of segment CD would prevent this syphon effect and stop flow from A to C. This provides the rationale for treating this type of paradoxical reflux by removal or ablation of the GSV. The post-treatment DUS findings confirm that such a strategy was effective since the Giacomini vein diminished in size and the SPJ regained competency thus confirming that the primary anomaly was not SPJ incompetence. Although it might be considered that the SSV might be at increased risk of becoming incompetent once paradoxical reflux in the Giacomini vein had been abolished, this did not seem to be the case again suggesting that the SPJ is not responsible for this type of reflux.

The finding in these two patients highlights the need for detailed DUS assessment to determine patterns of reflux before planning a definitive treatment for varicose veins, particularly when an endovenous ablation technique is to be employed. Further studies with longer follow up are required to establish long term efficacy of this method of treatment for paradoxical reflux. Although alternative management might include ablation of the Giacomini vein, if the GSV is left untreated reflux will persist with the varicosities filling via other GSV tributaries. In view of this, we believe that the approach described in this paper should be considered for other similar patients.